Shawn Judson, Ed.D

     Board of Trustees

Superintendent

Douglas M. Claflin

     Brynna Cadman

Assistant Superintendent of Business Services

     Robert Garcia

Terry Embleton

     Dayna Karsch

Assistant Superintendent of Personnel Services

     David W. Long

Charlayne Sprague

     Mondi M. Taylor

Assistant Superintendent of Instruction/Pupil Services

 
 

1883

 
 

6061 East Avenue, Etiwanda, California 91739

 

www.etiwanda.k12.ca.us

 

(909) 899-2451     FAX (909) 803-3033

 

APPROVAL REQUEST FOR PROGRAMS / ACTIVITIES

FOR BEFORE, DURING & AFTER-SCHOOL PROGRAMS

PLEASE SUBMIT REQUEST 2 WEEKS PRIOR TO THE EVENT

School:

Grade: 

Program/Activity (provide description):

Location:  

Date (s):         To    

Time (s):    :      To     :

Vendors / Props / Equipment / Other:  

Proof of Insurance – (select one):

This is a school/site sponsored program. The Etiwanda School District will provide insurance.

School sponsored programs involving vendor participation will require, of each vendor, a
      certificate of liability insurance (see the
below-listed Insurance Requirements).

1.The Contractor shall provide and maintain, General Liability insurance of a $1,000,000.00 minimum and to issue to the DISTRICT a valid and current Certificate of Insurance naming the DISTRICT as additional insured. (BP 3312)

2.Insurance Requirements

The certificate holder shall be Etiwanda School District 6061 East Avenue, Etiwanda, CA 91739

Etiwanda School District is to be named as additional insured

The Description of Operations information must be completed

When the named consultant/lecturer/presenter, or any person in their employment, will have or has the potential to have unsupervised contact with students, FINGERPRINT CLEARANCE IS REQUIRED. Please contact the Business Services Department for the necessary paperwork.

IMPORTANT REMINDER: If the activity involves a field trip, you must complete the FieldTrip Checklist, which includes directions regarding emergency Epipens.

Signature of Principal

 

Date

This is a PTA or PTO sponsored program. The PTA or PTO will carry all liability insurance coverage.
      A copy of the current PTA/PTO certificate of insurance, naming the ESD as Additional Insured, shall
      be forwarded to the ESD Risk Services Department.

Signature of PTA/PTO President

 

Date

For assistance, please contact Renee Peccoralo at (909) 803-3132 or Melinda Colgrove (909) 803-3116.

Updated July 2015 Forms/ProgramActivities/Master.doc